Excessive and inappropriate use of antibiotics in hospitalised patients contributes to the development and spread of antibiotic resistance. Implementing a stewardship programme to curb the problem requires information on antibiotic use. This study describes a multicentre point prevalence of antibiotic use among paediatric inpatients in Ghana.
Trang 1R E S E A R C H A R T I C L E Open Access
Antibiotic prescribing in paediatric
inpatients in Ghana: a multi-centre point
prevalence survey
Appiah-Korang Labi1,2, Noah Obeng-Nkrumah3* , Gifty Sunkwa-Mills4,5, Antoinette Bediako-Bowan6,7,8,
Christiana Akufo9, Stephanie Bjerrum4, Enid Owusu3, Christabel Enweronu-Laryea10, Japheth Awuletey Opintan5, Jorgen Anders Lindholm Kurtzhals1,11and Mercy Jemima Newman5
Abstract
Background: Excessive and inappropriate use of antibiotics in hospitalised patients contributes to the development and spread of antibiotic resistance Implementing a stewardship programme to curb the problem requires information
on antibiotic use This study describes a multicentre point prevalence of antibiotic use among paediatric inpatients in Ghana
Methods: Data were extracted from a multicentre point prevalence survey of hospital acquired infections in Ghana Data were collected between September 2016 and December 2016 from ten hospitals through inpatient folder and chart reviews using European Centre for Disease Control (ECDC) adapted data collection instrument From each site, data were collected within a 12-h period (8 am to 8 pm) by a primary team of research investigators and a select group
of health professionals from each participating hospital
Results: Among 716 paediatric inpatients, 506 (70.6%; 95% confidence interval (CI): 67.2 to 74.0%) were on antibiotics
A significant proportion of antibiotics (82.9%) was prescribed for infants compared to neonates (63.9%) and adolescents (60.0%) The majority of patients (n = 251, 49.6%) were prescribed two antibiotics at the time of the survey The top five classes of antibiotics prescribed were third generation cephalosporins (n = 154, 18.5%) aminoglycosides (n = 149, 17.9%), second generation cephalosporins (n = 103,12.4%), beta lactam resistant penicillins (n = 83, 10.0%) and nitroimidazoles (n
= 82, 9.9%) The majority of antibiotics (n = 508, 61.0%) were prescribed for community acquired infections The top three agents for managing community acquired infections were ceftriaxone (n = 97, 19.1%), gentamicin (n = 85, 16.7%) and cefuroxime (n = 73, 14.4%)
Conclusion: This study points to high use of antibiotics among paediatric inpatients in Ghana Cephalosporin use may offer an important target for reduction through antibiotic stewardship programmes
Keywords: Antibiotic use, Children, Paediatric, Point prevalence, Ghana
Background
Antibiotic resistance is a public health threat of global
proportions [1] It is associated with increased costs of
health services, prolonged hospital stays and poor
clin-ical outcomes [2,3] There are increasing reports of
anti-biotic resistance in hospital-acquired as well as
community-acquired infections in low resource coun-tries such as Ghana, with a significant number of cases reported among children [4–8] This situation, if not ur-gently addressed, has the potential to jeopardize gains made in the management of infectious diseases due to shortfalls in healthcare financing, poor diagnostic cap-abilities and non-availability of newer therapeutic agents for the management of drug resistant bacteria [9] Antibiotic resistance, though a natural phenomenon, has been accentuated by inappropriate use of antibiotics which selects for and contributes to the spread of
* Correspondence: successfulnoahforchrist@yahoo.com
3 Department of Medical Laboratory Sciences, School of Biomedical and
Allied Health Sciences College of Health Sciences, University of Ghana, P.O.
Box KB 143, Accra, Ghana
Full list of author information is available at the end of the article
© The Author(s) 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made The Creative Commons Public Domain Dedication waiver
Trang 2resistant bacteria [10–13] Strategies that have been
pro-posed to counter antibiotic resistance include improved
infection prevention and control programmes;
surveil-lance of antimicrobial resistance; surveilsurveil-lance of
anti-biotic use; and implementation of antimicrobial
stewardship programmes [1,14–17]
To develop antimicrobial stewardship programmes,
there is a need to acquire accurate baseline data on
anti-biotic prescription practice [18] As an alternative to
long term prospective surveillance that is usually not
available in low resource countries, point prevalence
sur-veys of antibiotic use have been found useful in
generat-ing such data [19–21] This study describes antibiotic
prescribing patterns among hospitalised children and
ad-olescents in Ghana using data from a multicentre point
prevalence survey conducted between September and
December 2016 [22] We describe antibiotic use across
paediatric age groups and hospital levels, indications for
antibiotic use, and targets for improved antibiotic use
within the population
Methods
Study design and population
The report presented here on antibiotic use in patients
≤18 years is a sub-analysis to a multicentre point
preva-lence survey of hospital acquired infections The study
design was a retrospective patient record review using
data collection instrument The study was conducted
among in-patients at ten hospitals in Ghana between
September and December 2016 [22] Details of the
methodology have been described elsewhere [22, 23]
Briefly, representative samples of acute care hospitals
were selected, using systematic random sampling,
ac-cording to size and hospital type (teaching/tertiary,
re-gional/secondary, and district/primary hospitals) Each
of the ten regions in Ghana was represented by one
hos-pital There are 3 teaching hospitals, 10 regional
hospi-tals, and about 162 district hospitals in Ghana [24]
Together these hospitals register a bed occupancy rate
of 60.4% (n = 8195) in 2017 for a total bed capacity of
12,806
Data collection
Data were collected from patient folders and treatment
charts using standardised forms adapted from the
Euro-pean Centre for Disease Control (ECDC) [23] Data
re-corded included type of antibiotic administered, route of
administration, indication for use, number of doses per
day, anatomic site targeted and duration of
administra-tion Medical records of all patients on admission on or
before 8 am on the day of the study were reviewed Data
collection was conducted within a 12-h period, i.e 8 am
to 8 pm For hospitals with large bed capacity (> 1000),
individual wards were investigated within a 12-h period
and the total time frame for data collection at all wards
of the hospital did not exceed one week Data collection from each hospital was performed by two teams: a pri-mary team of research investigators and a selected group
of health professionals from the participating hospital
Definitions
Data on antibiotic use was recorded when a patient was actively on antibiotics at the time of the survey As per ECDC guidelines, indication for antibiotic use was assigned to either community acquired infection (infec-tion with symptoms occurring within 48 h of hospital admission) or hospital acquired infection (an active in-fection with signs and symptoms occurring after 48 h of admission or when the patient presented with an infec-tion but had been readmitted less than two days after a previous discharge from a hospital) Unknown indica-tions included antibiotic treatments with missing infor-mation on origin of active infection Diagnosis of infection was categorised according to anatomic systems [23,25]: eye; ear, nose, throat, larynx and mouth (ENT); respiratory tract (including pneumonia and acute bron-chitis); cardiovascular system (CVS) including endocar-ditis and vascular grafts; gastrointestinal tract (GIT); intra-abdominal organs including those of the hepato-biliary system; skin, soft tissue, bone and joint (SSTBJ); central nervous system (CNS); genitourinary and gynae-cological (GUOB); and those with undefined infection sites
Data handling and statistical analysis
Data was analysed using Access (Microsoft Office 2016) and Statistical Package for Social Sciences (SPSS, Ver-sion 21.0) Antibiotics were classified according to the Anatomical Therapeutic Chemical Classification System (ATC) [26] We compared prevalence of antibiotic use across different hospital levels and across different age groups using the chi-square tests for multiple propor-tions with Marachuilo post hoc analysis Two –tailed p-values < 0.05 were considered statistically significant
We categorized our study as neonates if ≤28 days; and infants if > 28 days to ≤2 years In the Ghanaian health-care system, patients aged 0 up to 13 years are attended
to in paediatric departments whilst those > 13 years are seen at adult departments We thus assigned the term children if aged > 2 years to≤13 years, and adolescents if aged > 13 years to≤18 years
Results
Data was collected from 2 tertiary hospitals, 3 secondary hospitals, and 5 primary hospitals (Table 1) The in-cluded hospitals had a total 4208 acute care beds, repre-senting 32.9% of the total bed capacity for government hospitals in Ghana, and an overall bed occupancy of
Trang 359.1% The median bed-size in a hospital was 304,
ran-ging from 139 to 1533
Hospital and patient characteristics
A total of 849 inpatients under the age of 18 years were
included Among these, 133 neonates were healthy and
only in hospital because their mothers had not been
dis-charged home None of these received antibiotics and
they were excluded from further analyses, leaving a total
of 716 patients included for analysis Baseline
demo-graphic data are shown in Table 1 Of the patients, 201
(28.1%) were from district hospitals, 175 (24.4%) from
regional hospitals and 340 (47.5%) from tertiary
hospi-tals The average duration of stay of the patients prior to
the survey was 8 days, this varied from 5 days in the
re-gional hospitals to 6 days in district hospitals and 9 days
in tertiary hospitals
Use of antibiotics
Out of 716 patients on admission, 506 [70.6%,
confi-dence interval (CI): 67.2 to 74.0] received at least one
antibiotic at the time of the survey There was a
signifi-cant difference between the proportions of patients
re-ceiving antibiotics in regional hospitals (83.4%), tertiary
(65.6%) and district hospitals (68.2%, p = 0.0001) The
proportion of antibiotic use among infants (82.9%) was
significantly higher compared to antibiotic use in
neo-nates (63.9%) and adolescents (60.0%) but similar to the
proportion of use among children (72.4%, p = 0.0001,
Table 1) Of patients on antibiotics, the majority (n =
251, 49.6%) were prescribed two antibiotics whereas
fewer received one antibiotic (n = 219, 43.3%), three
anti-biotics (n = 33, 6.5%) or four antianti-biotics (n = 3, 0.6%)
This trend was observed among the neonatal, infant and
adolescent populations, but not for children who were
more likely to receive one antibiotic (Fig 1) A total of
831 individual antibiotics were prescribed; 694 (83.5%)
were administered via the intravenous route and 137 (16.5%) via the oral route, which was similar across dis-trict, regional and tertiary hospitals Average duration of antibiotic administration at the time of the survey was 4 days, ranging between 1 and 13 days Average duration
of antibiotic administration was 3 days for district hospi-tals, 4 days for regional hospitals and 6 days for tertiary hospitals
Antibiotic utilisation at different types of healthcare facilities
Figure 2 shows antibiotic use by class (ATC Level 4) across the different hospital types The top five classes of antibiotics used (N = 831) were third generation cephalo-sporins (n = 154, 18.5%), aminoglycosides (n = 149, 17.9%), second generation cephalosporins (n = 103, 12.4%), beta lactam resistant penicillins (n = 83, 10.0%) and nitroimidazoles (n = 82, 9.9%) The proportion of third generation cephalosporin used was similar at the three hospital levels, i.e tertiary (n = 74, 18.9%), regional (n = 46, 18.9%), district (n = 34, 17.3%, p = 0.9) Similar proportions of aminoglycosides were used in tertiary (n
= 84, 21.5%) and regional (n = 39, 16%) hospitals, whereas significantly lower proportion were used in dis-trict hospitals (n = 26, 13.2%) compared to tertiary hospi-tals (p = 0.03) A significantly higher proportion of second generation cephalosporins were used in district hospitals (n = 48, 24.4%) compared to tertiary (n = 26, 6.6%) and regional hospitals (n = 29, 11.9%, p = 0.001) Carbapenems were only used in tertiary hospitals (n = 7, 0.8%) Of third generation cephalosporins prescribed, ceftriaxone was the commonest (n = 124, 80.5%) com-pared to ceftazidime (n = 1, 0.6%) and cefpodoxime (n =
1, 0.6%) Among the aminoglycosides, gentamicin (n =
114, 76.5%) and amikacin (n = 35, 23.5%) were the only prescribed agents, with amikacin being prescribed only
in tertiary hospitals Cefuroxime (n = 103) was the only
Table 1 Prevalence of antibiotic use by age and across type of hospital
Patient characteristics Number of patients on Prevalence of antibiotic use
Age group a
Hospital type
a
≤28 days, neonates; > 28 days to ≤2 years, infants; > 2 years to ≤13 years, children; > 13 years to ≤18 years, adolescents; %, percentage, CI confidence interval
Trang 4prescribed second generation cephalosporin in all
healthcare facilities Cloxacillin (n = 83) and
metronida-zole (n = 82) represent the only agents used across all
healthcare facilities in the beta lactam resistant
peni-cillin and nitroimidazole classes respectively Among
carbapenems, meropenem was the only agent
pre-scribed (n = 7) (Fig 2)
Antibiotic utilisation among different age groups
The five most common antibiotics used among neonates
were gentamicin (n = 56, 22%); cloxacillin (n = 50,
19.9%); ampicillin (n = 48, 18.9%); amikacin (n = 32,
12.6%); and cefotaxime (n = 25, 9.8%) (Fig.3) Among
in-fants, ceftriaxone (n = 37, 19.2%), cefuroxime (n = 32,
16.6%), gentamicin (n = 31, 16.1%), ampicillin (n = 13,
6.7%), crystal penicillin (n = 13, 6.7%) and metronidazole
(n = 13, 6.7%) were the top six antibiotics used Among children, the five most common antibiotics used were ceftriaxone (n = 66 (21.8%), cefuroxime (n = 57, 18.8%), gentamicin (n = 26, 8.5%), ciprofloxacin (n = 24, 7.9%) and amoxicillin-clavunalic acid (n = 23, 7.6%)
Indication for antibiotic use
Out of the 831 antibiotics prescribed, 508 (61%) were prescribed for community-acquired infections, 86 (10.3%) for hospital-acquired infections, 197 (23.7%) for prophylaxis and 40 (4.8%) for unknown reason (Table2) The top three agents for managing community-acquired infections were ceftriaxone (n = 97, 19.1%), gentamicin (n = 85, 16.7%) and cefuroxime (n = 73, 14.4%) The common agents used for surgical prophylaxis were
Fig 2 Antibiotic use by ATC level 4 across hospital category Others include nitrofurantoin and co-trimoxazole
Fig 1 Number of antibiotics prescription per patients ’age category across hospital type
Trang 5metronidazole (n = 20; 28.2%), amoxicillin-clavulanic
acid (n = 15, 21.1%) and cefuroxime (n = 13, 18.3%)
Based on the anatomic site, antibiotics were mainly
prescribed for undefined reasons (n = 328, 39.5%),
followed by the respiratory system (n = 196, 23.6%) and
skin, soft tissue, bone and joint infections (n = 131,
15.8%) (Table 3) Infection without a defined focus
formed the majority of the undefined reasons for
anti-biotic use in neonates The top three antianti-biotics used in
managing infections with undefined focus were
gentami-cin (n = 59, 18.0%), ceftriaxone (n = 57, 17.4%) and
ampi-cillin (n = 45, 13.7%) For respiratory tract infections,
gentamicin (n = 35, 17.9%), cefuroxime (n = 34, 17.3%)
and ceftriaxone (n = 2, 14.8%) were the three most
com-monly used antibiotics The top three antibiotics
pre-scribed for skin, soft tissue, bone and joint purposes
were metronidazole (n = 24, 18.3%), cloxacillin (n = 23,
17.6%) and clindamycin (n = 20, 15.3%)
Discussion
To the best of our knowledge this study presents one of
the few multicentre studies on antibiotic use among
hos-pitalised paediatric patients from Africa and the first
from Ghana It provides current patterns of antibiotic
prescribing practices in this population in Ghana and
can serve as a baseline for future comparison We
ob-served that 71% of the hospitalised paediatric and
ado-lescent patients were prescribed antibiotics with a high
percentage of use among infants and neonates This
fig-ure is comparable to a 69.4% rate of antibiotic use
ob-served among children in a recent single site study from
Korle-bu Teaching Hospital in Ghana [27] The rate is
comparable to findings from the United States of
America [28], but higher than 36.7% recorded in a re-cent worldwide survey of antibiotic use in children [29] The lowest antibiotic use was reported for tertiary hos-pitals This may be attributed to the fact that doctors in tertiary hospitals have more opportunities for rational antibiotic use: through participation in continuing edu-cation, consultations with senior physicians, and re-search [1,14–17,30] Although we accept the possibility that doctors’ practices on antibiotic use in tertiary hospi-tals may still be insufficient [27], it is notable that doc-tors coming from primary healthcare institutions have poorer knowledge, attitudes and practices on antibiotic use [31,32] Analysis of data from the Chinese Nosoco-mial Infection Control Surveillance Networks reveals that, compared with large secondary and tertiary hospi-tals, excessive and improper use of antibiotics is more severe in primary health care facilities [33, 34] In some European Countries, published data suggest higher anti-biotic use in tertiary health facilities [25] The heterogen-eity in the level antibiotic use across hospital types is highlighted in the recent study that reviewed published works and online surveillance reports on antibiotic con-sumption in acute care hospitals between the years 1997 and 2013 [35] In their pooled estimate for antibiotic consumption, there was a non-significant trend for higher antibiotic consumption in tertiary compared to non-tertiary hospitals
In our study, we observed a very high rate of paren-teral antibiotic use, especially in tertiary hospitals It has been suggested that high rates of parenteral antibiotic use persists among children because of limited options for oral broad spectrum antibiotics with appropriate for-mulations and the challenges of oral administration of
Fig 3 Proportion of antibiotic use (ATC level 5) across patients ’ age category
Trang 6medications in young children [36] Similar high rates of
parenteral antibiotic use have been observed in other
settings [18, 27] Parenteral antibiotic use is a known
quality indicator of antibiotic prescribing practices [21,
37] Low rates of intravenous antibiotic use are preferred
since they are associated with lower levels of
thrombo-phlebitis, cannula related infections, lower cost of care
and early discharge [37, 38] There was a high usage of
third and second generation cephalosporins as well as
aminoglycosides among patients in all types of
health-care facilities in the country This may be due to the
abundance of cheap generic options on the market, as
well as their availability on the national health insurance
scheme at all levels of the health care system [39]
Glo-bally, cephalosporins are used empirically in patient care
due to their low toxicity, they are however known to
contribute to the development and spread of multi-drug
resistant infections [40] Extensive use of third
gener-ation cephalosporins among primary and secondary level
facilities may be contributing to the rise and spread of
extended spectrum beta lactamase-producing bacteria in
Ghanaian hospitals [4,41] This phenomenon may limit
the usefulness of these agents at the tertiary level in
managing referred cases Low prescribing rates of
antibi-otics such as carbapenems and vancomycin were
ob-served from this study These agents were only used in
tertiary healthcare facilities and mainly in one healthcare facility, the Korle-Bu Teaching Hospital Low prescrip-tion rates of these agents could be accounted for by their unavailability on the national health insurance scheme and the high cost associated with out of pocket purchase [39] This practice has the potential to slow down the development and spread of carbapenemase-producing and vancomycin-resistant bacteria among paediatric patients
The highest use of gentamicin, amikacin, ampicillin and cloxacillin was in the neonatal age group These agents are recommended by the standard treatment guidelines of Ghana and by other international guide-lines for neonatal infections [42, 43] Our data suggest a strong adherence to the recommended treatment proto-cols among the neonatal age group Similar findings have been reported in recent studies on antibiotic use among children [29, 44, 45] Amikacin use in this study was accounted for by one tertiary healthcare facility i.e Korle-Bu Teaching Hospital In this facility, amikacin in combination with cloxacillin forms the standard treat-ment protocol for infections in the neonatal intensive care unit This protocol has been in place for the past 6 years and was instituted after a review of the unit’s anti-biogram showed increasing resistance to ampicillin/gen-tamicin combination which was the previously
Table 2 Indications for prescribing antimicrobial drugs (ATCalevel 5) and the five most common antibiotics used
Indication for antibiotic use Top 5 antibiotic use among paediatric inpatients
All indications ( n = 831) Ceftriaxone
( n = 124, 14.9%) Gentamicin(n = 114, 13.7%)
Cefuroxime ( n = 103, 12.4%) Cloxacillin(n = 83, 9.9%)
Metronidazole (n = 82, 9.8%) Community acquired infections (n = 508) Ceftriaxone
(n = 97, 19.1%)
Gentamicin (n = 85,16.7%)
Cefuroxime (n = 73, 14.4%)
Cloxacillin ( n = 48, 9.4%) Metronidazole( n = 47, 9.3%) Hosptal acquired infections ( n = 86) Cloxacillin
( n = 12, 14.0%) Gentamicin(n = 12, 14.0%)
Cefuroxime (n = 8, 9.3%)
Ciprofloxacin (n = 7, 8.1%)
Amikacin (n = 6, 7.0%) Ampicillin Ceftriaxone Meropenem Medical prophylaxis
( n = 126) Ampicillin( n = 17, 13.5%) Gentamicin( n = 1, 13.3%) Cefotaxime( n = 16, 12.7%) Amikacin(n = 14, 11.1%)
Crystal penicillin (n = 13, 10.3%) Cloxacillin
Surgical prophylaxis
( n = 71) Metronidazole(n = 20, 28.2%)
Amoxicillin-clavulanic acid (n = 15, 21.1%)
Cefuroxime (n = 13, 18.3%)
Ceftriaxone (n = 7,9.9%)
Ampicillin (n = 4, 5.6%) Ciprofloxacin Unknown
( n = 40) Ceftriaxone(n = 8, 20.0%)
Amox-clavulanic acid (n = 4, 10.0%)
Metronidazole (n = 3, 7.5%)
Amikacin (n = 2, 5.0%)
Erythromycin (n = 1, 2.5%) Ciprofloxacin Cefuroxime Azithromycin Clindamycin Crystal penicillin Co-trimoxazole
Cloxacillin Gentamicin
a
ATC Anatomical Therapeutic Chemical Classification System
Trang 7recommended standard treatment [46] In contrast,
there was a sharp difference in the classes of antibiotics
used among the other age groups, they were mainly
treated with broad spectrum agents such as third and
second generation cephalosporins Antibiotics were
commonly prescribed for infections of undefined origin,
in particular among neonates This may reflect
chal-lenges with diagnosing infections in neonates with a
re-sultant high rates of empirical antibiotic use
The use of broad spectrum antibiotics among children
is a quality indicator for antibiotic prescribing as it can
lead to the development and spread of antibiotic
resist-ance [29] Use of such broad spectrum antibiotics in
chil-dren may reflect the lack of adherence to suggested
standard treatment guidelines The prescribing pattern
may also be affected by the relatively low utilisation of
microbiology culture services observed in an earlier study
[22] The limited availability and usage of clinical
micro-biology services thus promotes empirical antibiotic
pre-scribing against susceptibility guided therapy; it also does
not allow for stepping treatment down from broader to
narrower spectrum antibiotics Several studies in Ghana
have shown an increase in the incidence of infections
caused by extended spectrum beta lactamase-producing
bacteria This may be a direct result of the high usage of
cephalosporins [4, 6, 41, 47] Metronidazole, amoxicillin
clavulanic acid and cefuroxime were the most common
antibiotics used for surgical prophylaxis High use of metronidazole as a prophylactic agent in surgery practice has been documented in other studies in Ghana [27, 48] Metronidazole used in combination with antibiotics with aerobic coverage has been found to prevent surgical site infections in abdominal surgeries [49, 50] Although this study did not assess the appropriateness of antibiotic pre-scribing there is evidence that metronidazole amoxicillin-clavulanic acid combination is commonly used despite the fact that it represents double cover for anaer-obic bacteria
Reducing antibiotic consumption through stewardship programmes is a major global strategy being advanced
to curb the development and spread of antibiotic resist-ance [14, 51–55] In resource limited countries like Ghana, third generation cephalosporins represent a safe broad-spectrum agent useful for the management of very severe Gram negative and positive infections Our study highlights third generation cephalosporins as a major antibiotic class for which antibiotic stewardship strategies are urgently needed to preserve their useful-ness among hospitalised paediatric patients Failure to preserve these agents may result in increased use of newer and more expensive agents like carbapenems and glycopeptides due to growing antibiotic resistance; a situation which may lead to a reversal of gains made in the management and control of infectious diseases
Table 3 Anatomic sites of infection and the five most common antimicrobial drugs (ATC level 5) prescribed
Anatomic
sites a Top 5 antibiotic use (ATCalevel 5) among paediatric patients
Resp
(n = 196)
Gentamicin
(n = 35, 17.9%)
Cefuroxime (n = 34, 17.3%) Ceftriaxone (n = 29, 14.8%) Amox-clav ( n = 18, 9.2%) Cloxacillin (n = 12, 6.1%)
C penicillin SSTBJ (n = 131) Metronidazole
(n = 24,18.3%)
Cloxacillin (n = 23, 17.6%) Clindamycin (n = 20, 15.3%) Cefuroxime (n = 19, 14.5%) Amox-clav (n = 17, 13.0%)
GIT ( n = 88) Metronidazole
(n = 29, 32.9%)
Cefuroxime (n = 17,19.3%) Ciprofloxacin (n = 13,14.8%) Ceftriaxone (n = 11,12.5%) Gentamicin (n = 7, 8.0%)
GUOB (n = 33) Metronidazole
(n = 8,24.2%)
Amox-clav (n = 7, 21.2%) Cefuroxime (n = 5, 15.2%) Ceftriaxone (n = 4, 12.1%) Ciprofloxacin (n = 3, 9.1%)
CNS
(n = 26)
Amox-clava
(n = 2, 7.7%)
Ceftriaxone (n = 11, 3.4%) Cloxacillin (n = 5, 1.5%) Metronidazole (n = 3,0.9%) Gentamicin (n = 1, 0.3%)
Meropenem UTI
(n = 14)
Cefuroxime
(n = 5, 35.7%)
Ciprofloxacin (n = 3, 21.4%) Other drugs b ( n = 6, 43.8%) – – Other sites
(n = 15)
Ceftriaxone
(n = 4, 26.6%)
Amox-clav (n = 2, 13.1%) Other drugsc(n = 4, 26.6%) – –
C penicillin a
UND (n = 328) Gentamicin
(n = 59,18.0%)
Ceftriaxone ( n = 57, 17.4%) Ampicillin (n = 45,13.7%) Cloxacillin ( n = 42,12.8%) Amikacin (n = 25,7.6%)
a
Resp respiratory tract, GIT Gastrointestinal tract, UTI Urinary tract infection, CNS Central nervous system, SSTBJ skin, soft tissue, bones and joints, GUOB
Genitourinary and obstetrics; Other sites comprise cardiovascular system and Ear, nose and throat; UND Undefined, Amox-clav Amoxicillin-clavulanic acid, C pencillin Crystal penicillin, ATC Anatomical Therapeutic Chemical Classification System
b
other drugs include crystal penicillin (n = 1), ceftriaxone (n = 1), gentamicin (n = 1), meropenem (n = 1), nitrofurantoin (n = 1), erythromycin (n = 1)
c
others include crystal penicillin (n = 1), ceftriaxone (n = 1), gentamicin (n = 1), meropenem (n = 1), nitrofurantoin (n = 1), erythromycin (n = 1)
Trang 8There is also the need for improved access to diagnostic
clinical microbiology services which would contribute to
improved diagnosis and management of conditions such
as sepsis and lead to a reduction in antibiotic use
This study has some potential limitations Although
the data presented here gives a good situation report of
publicly funded health facilities, findings may not be
dir-ectly extended to private healthcare facilities We
re-corded the duration of antibiotic treatment, but the
appropriateness and length of antibiotic use was not
assessed at the individual level, nor was the indication
for culture before antibiotic therapy This could have
provided significant information to guide antibiotic
stewardships strategies and may be considered in future
surveys Another limitation is the study’s time window
Being a point prevalence study, information on antibiotic
use was collected at a single point in time over the
period between September and December 2016 This
de-sign would not capture the seasonality of infections and
antibiotic prescriptions Conducting this survey
through-out multiple time points would have allowed for a more
robust estimate of inpatient antibiotic prescribing in
Ghana However, we did not have the necessary capacity
to repeat this multi-site point prevalence study more
than once Despite these limitations we believe the use
of standardized international protocol [23] for our study
gives us robust evidence of antibiotic use among
hospi-talized paediatric inpatients in Ghana and serves as a
bench mark for future comparison
Conclusion
Our study shows high use of antibiotics among
paediat-ric inpatients in Ghana It also highlights key differences
in antibiotic use among neonates and the other
paediat-ric population; neonates are likely to be prescribed an
aminoglycoside and a penicillin as opposed to the
dom-inant use of cephalosporins among the other age groups
Studies of the appropriateness of antibiotic use are
ur-gently needed to guide antibiotic stewardship strategies
aiming at reducing the use of agents such as
cephalospo-rins in order to conserve their lifespan
Abbreviations
CI: Confidence interval; ECDC: European Center for Disease Prevention and
Control; HAI: Healthcare associated infection; IQR: Interquartile range;
KBTH: Korle-Bu Teaching Hospital; PPS: Point prevalence study; WHO: World
Health Organization
Acknowledgements
The authors thank Mr Edmund Tetteh Nartey for his enormous help during
the database development and data analysis We also thank all the members
of the data collection team, management and staff of all the participating
hospitals.
Funding
The study was funded by Danish Ministry of Foreign Affairs (DANIDA grant
no 16-PO1-GHA) The funders had no role in the design of the study and
Availability of data and materials Data is available upon request to the corresponding author.
Authors ’ contributions AKL, NON, SB, GSM, EO, CA, ABB, CEL, JAO, JALK and MJN conceptualized the study; participated in its design, coordination, and questionnaire administration; and helped to draft the manuscript AKL, NON performed the statistical analysis The manuscript was revised for intellectual content by CEL, JALK and MJN All authors have read and approved the final manuscript for submission Ethics approval and consent to participate
The study received ethical approval from the Ethics and Protocol Committee
of the Ghana Health Service (Protocol No: GHS-ERC08/05/16) as well as the Institutional Review Board of the Korle-Bu Teaching Hospital (Protocol No: KBTH-STC/IRB/0004/2016) Individual informed consent was waived for the conduct of this study as it was deemed a surveillance activity.
Consent for publication Not applicable.
Competing interests The authors declare that they have no competing interests.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Author details
1 Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark 2 Department of Microbiology, Korle-Bu Teaching Hospital, P.O Box 77, Accra, Ghana 3 Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Sciences College of Health Sciences, University of Ghana, P.O Box KB 143, Accra, Ghana 4 Department of Public Health, Global Health Section, University of Copenhagen,
Copenhagen, Denmark 5 Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, College of Health Sciences, University
of Ghana, P.O Box 143, AccraKorle-BuGhana 6 Department of Animal Science, University of Copenhagen, Copenhagen, Denmark 7 Department of Surgery, School of Medicine and Dentistry, College of Health Sciences, P O Box 4326, Accra, Ghana.8Department of Surgery, Korle-Bu Teaching Hospital, P.O Box
77, Accra, Ghana 9 Institutional Care Division, Ghana Health Service, PMB Ministries-Accra, Accra, Ghana 10 Department of Child Health, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, P.O.Box 4326, Accra, Ghana.11Centre for Medical Parasitology, Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark.
Received: 21 June 2018 Accepted: 5 December 2018
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